24 February 2023

This is a media release by Simpson Millar Solicitors, reshared by INQUEST

Before Assistant Coroner Diane Hocking
Leicester City & South Leicestershire Coroner's Court
21 - 23 February

The inquest into the death of 36-year-old Jay Baxter concluded on 23 February 2023. Jay was found hanged on 26 October 2019. Leicester City Assistant Coroner, Diane Hocking, returned a conclusion of suicide. She was concerned about the multi-agency communication and directed that Leicestershire Police and Leicestershire Partnership NHS Trust produce a combined report evidencing changed practice in the last 4 years.

Jay’s family feel that the evidence they heard clearly shows that Jay was failed by multiple state agencies both in the lead up to his tragic death and in the investigation afterwards.

Jay suffered from complex mental health problems as well as drug addiction. In the last year of his life, his mental health problems worsened considerably. He began to hear auditory hallucinations telling him to kill himself and to harm others. He presented at A&E multiple times seeking inpatient admission and treatment but was denied that opportunity. To compound matters, Jay became homeless in the last months of his life. On several occasions, Jay warned that he would kill himself, including by hanging and warned that the voices were getting worse and he was worried he would hurt someone as a result of the voices. He also engaged in self-harming behaviour, including taking an overdose. The evidence heard at the inquest showed a failure on the part of Leicestershire Partnership NHS Trust to take Jay’s reports seriously and a complacency that he would ‘self-rescue’ by presenting at A&E. This complacency meant that risk assessments were not updated, and ultimately that the escalating risk Jay posed to himself and others as a result of his deteriorating mental health in the last week of his life was not recognised and ultimately not acted upon.

Jay was treated as ‘disengaged’ and ‘not engaging’ with mental health and drug addiction agencies despite evidence to show he was communicating regularly with them. Jay’s family feel that the lack of flexibility without any proper consideration of why Jay was finding it hard to engage in the community meant that he was written off as not engaging rather than helped to engage. Jay’s family feel that this model of engagement is not appropriate for people with multiple vulnerabilities such as homelessness, drug addiction and psychosis and sets them up to fail. The focus on Jay’s substance misuse issues acted as a bar to his receiving the inpatient treatment which his family feel he desperately needed. There was a lack of inter-agency communication which meant that there was never a coordinated approach to helping Jay which addressed his social, mental and safeguarding needs.

In the week leading up to Jay’s death, he was clearly experiencing an acute mental health crisis. This was brought to the attention both of Leicestershire Police, and Leicestershire Partnership NHS Trust on multiple occasions. The family strongly feel that a failure to take action during this time period meant that a crucial opportunity to save Jay’s life was missed. The failure to communicate with Jay’s family meant that they did not have a proper opportunity to help and support him.

Jay’s family have been disappointed in the investigation by Leicestershire Police following Jay’s death. Inconsistencies in the accounts given to the police as to the circumstances leading to Jay’s death should have prompted a full and forensic investigation. Instead, the family feel that Leicestershire Police failed to properly follow up on these lines of investigation and treat the circumstances surrounding Jay’s death with the scrutiny they warrant.  

Jay was a kind person, a great and devoted father and a much-loved brother and son who will be sadly missed by his family. Sadly, Jay’s family feel that the systemic problems which led to Jay’s death persist and emphasise the need for meaningful change in supporting those with mental health and addiction issues to avoid other families experiencing tragic bereavement. The family also felt that the inquest process was made far more difficult and traumatic by the approach of Leicestershire Police and Leicestershire Partnership NHS Trust in the years since Jay’s death. The family feel that neither organisation acted with the candour and openness expected of them in assisting the investigation into Jay’s death.

Jay’s Dad was represented by Aimee Brackfield of Simpson Millar Solicitors and Mira Hammad of Garden Court North Chambers. Ms. Brackfield commented “Jay’s family have endured the harrowing process of exploring what happened to their much-loved son and brother with enormous strength and dignity. We echo the family’s call for substantive change to support people in vulnerable positions such as Jay.”


Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.